I Despise Prior Authorizations

Ah, prior authorizations.

For those of you that don’t work in a pharmacy or doctor’s office, the phrase “prior authorization” doesn’t strike fear into your hearts.

Today, I am victorious over the prior authorization system. It was a long and hard battle; my patient and I were both thoroughly frustrated. But she finally was able to pick up her prescription after 3 months of war between her doctor’s office, me, and her insurance company.

She was written a prescription for Lyrica in June. She had just become eligible for Medicare, and signed up for the AARP Medicare Part D Plan (for prescriptions) as well as for Medicare Part B (for doctors’ visits). When she brought me the prescription, I tried to run it through the AARP plan. Unfortunately, it was….

REJECTED: Prior Authorization Required.

This means that her doctor’s office needs to contact the insurance company and say that she has tried and failed other therapies for her diabetic neuropathy (amitriptyline, gabapentin). This is because Lyrica is usually a second or third-line agent; it is new and expensive. Insurance companies don’t want to have to pay for it if they don’t have to. So they make the doctor’s office jump through hoops. Standard procedure. I sent the doctor’s office a fax saying just that. I even included the insurance company’s telephone number, her insurance ID number, and the exact rejection message.

First, the doctor’s office DID the prior authorization. They even faxed me a copy of the form they sent to the insurance company. Problem was, they did a prior authorization through the WRONG INSURANCE COMPANY. They submitted the form to her old insurance, the one she had before she became eligible for Medicare and signed up for AARP. They didn’t read my fax that included an insurance company phone number and insurance ID.

So, after some phone tag and confusion, I sent them another fax. I wrote out that she was on MEDICARE PART D through AARP. I asked for a prior authorization for my patient. Again, I included a phone number and insurance ID. She is in constant burning pain from her neuropathy. Her current treatments weren’t working. I wanted to help her.

The next faxed letter I get is from Medicare, not AARP. The doctor’s office tried to get her Lyrica prior authorization through Medicare Part B. Now, Part B doesn’t cover things through the pharmacy except diabetic supplies, some nebulized medications and a few injectables/chemotherapy agents. They cover virtually no oral medications. They denied the prior authorization for Lyrica.
Obviously.
Who do they have working at this doctor’s office?
I
called. Left messages. Faxed. Gave the patient the fax to take to the office. I sent a fax spelling out EXACTLY what the office needed to do. I bolded, circled, underlined the insurance company’s phone number and her insurance ID number.

Today, all my hard work, nagging, and wasted paper has paid off. Her Lyrica went through - and her copay came back at $5. When I called to tell her, she almost cried.